A poliomyelitis survey the simple way: the Tanzanian experience.

A simple cost effective survey to assess the need for a rehabilitation service for individuals disabled by poliomyelitis was carried out making the maximum use of the existing government administration. The field team consisted solely of a medical officer and a health officer. The prevalence rate for paralytic poliomyelitis in the Mbeya region of Tanzania was 2.95/1000 persons. The rate for children under 10 years was 1.15/1000, suggesting that the expanded immunisation programme started in 1977 was being successful. With approximately 4000 cases of paralytic poliomyelitis in the Mbeya region a rehabilitation service would seem to be justified. If poliomyelitis surveys are required for rehabilitation purposes they must include all age groups. In this survey, had only school children been considered, as recommended by the World Health Organisation, two thirds of the cases would have been excluded, thereby hardly justifying a rehabilitation service.     

THE PRECIPITATION OF CLINICAL POLIOMYELITIS BY INJECTIONS

In records of 1,321 cases of poliomyelitis in the city of Los Angeles in 1948, notation was made as to whether or not the patient had been vaccinated against smallpox or had received an injection of one kind or another in the period preceding the onset of poliomyelitis.In children under 12 years of age, the incidence of poliomyelitis was slightly higher among those who had had recent vaccination or injection than among those who had not, and the incidence of paralysis was slightly greater also. However, the disparities were not considered statistically significant. They were not wide enough to warrant withholding immunization against other serious diseases on the strength of the possibility that in so doing a slight reduction in the incidence of crippling poliomyelitis might be effected.     

Incidence of poliomyelitis; the effect of tonsillectomy and other operations on the nose and throat

A statistical survey was made of all the cases of poliomyelitis occurring in all of Los Angeles County during the three years of 1949, 1950 and 1951 in an attempt to determine the effect of operations on the nose and throat on the incidence of poliomyelitis. Tonsillectomy and adenoidectomy were the only operations noted with any degree of frequency. Yet, in the total of 3,601 cases of poliomyelitis that occurred in this three-year period there were only 20 (0.55 per cent) in which the patient had had recent tonsillectomy and adenoidectomy. The incidence of this disease in patients who had had tonsillectomy and adenoidectomy was compared with the "expected" incidence as determined from the incidence in other patients, in the same age group. There was no significant difference between actual and expected incidence even during the summer months when most cases of poliomyelitis occurred. The same was true with regard to recently tonsillectomized patients in the epidemic months of July through October. In a separate survey of 675 patients with poliomyelitis, it was noted that only 30 per cent ever had had tonsillectomy or adenoidectomy. Inasmuch as it is estimated that one of every three persons in the general young population nowadays has had tonsillectomy and adenoidectomy, this figure is no more or less than could be expected.     

Outside Europe. Is poliomyelitis a serious problem in developing countries?--the Danfa experience.

Children were examined for lameness in the Danfa Project district of rural Ghana to assess the impact of endemic poliomyelitis and to test a widely held hypothesis that paralytic poliomyelitis is relatively rare in such districts (less than 1 per 1000 children affected). The observed prevalence of lameness attributable to poliomyelitis was 7 per 1000 school-aged children, and the annual incidence is estimated to be at least 28 per 100 000 population. Although no evidence for an epidemic was found, these rates are comparable with those in the USA and Europe during the years of severe epidemics and indicate that a high price is being paid in the Danfa district for the natural acquisition of immunity. As a result, immunisation against poliomyelitis has been given high priority. A teacher questionnaire was also tested for use in postal surveys as a rapid means of estimating the prevalence of lamenes attributable to poliomyelitis in countries with a reasonable network of primary schools.     

The 1952 Outbreak of Encephalitis in California (A Symposium): EPIDEMIOLOGIC ASPECTS

For the most part, epidemiologic phenomena observed in the outbreak of encephalitis in 1952 accorded with patterns that had been apparent in previous years. Ninety-seven per cent of the 414 laboratory-confirmed cases of western equine and St. Louis encephalitis in humans occurred in the 20 Central Valley counties. The cases of western equine encephalomyelitis in horses were generally scattered over the state. In the Central Valley most of the cases in horses were in animals less than two years of age; elsewhere the incidence was higher in older horses.There were no laboratory-confirmed cases of western equine or St. Louis encephalitis in humans earlier than June or later than October.In 1952 there were far more cases of western equine than of St. Louis encephalitis—a departure from the pattern in the previous seven years when there were about as many of one as of the other. No known satisfactory index is available for the prediction of the extent or type of outbreaks in humans.Approximately one-third of the cases of western equine encephalitis were in patients less than one year of age, whereas there were no cases of the St. Louis disease in patients that young.The incidence of western equine encephalitis in persons under 5 years of age was about the same for girls as for boys. In higher age brackets, males with western equine encephalitis outnumbered females 2 to 1. The corresponding ratio for St. Louis encephalitis was only 1.2 to 1.     

Western equine encephalitis in infants; a report on three cases with sequelae

Approximately one-third of the laboratory-confirmed cases of Western equine encephalitis occur in children under the age of 10. The present paper describes three instances of Western equine encephalomyelitis virus infection in infants under one year of age, together with the resultant sequelae. The difficulties associated with diagnosis of central nervous system disturbances in very young children are discussed, and it is pointed out that in view of the frequent occurrence of clinical infections with the arthropod-borne encephalitis viruses these agents should be given serious consideration as a cause of acute central nervous system infection in childhood and as the possible etiology for obscure, severe neurological disturbances in the pediatric age groups.     

WESTERN EQUINE ENCEPHALITIS IN INFANTS—A Report on Three Cases with Sequelae

Approximately one-third of the laboratory-confirmed cases of Western equine encephalitis occur in children under the age of 10. The present paper describes three instances of Western equine encephalomyelitis virus infection in infants under one year of age, together with the resultant sequelae. The difficulties associated with diagnosis of central nervous system disturbances in very young children are discussed, and it is pointed out that in view of the frequent occurrence of clinical infections with the arthropod-borne encephalitis viruses these agents should be given serious consideration as a cause of acute central nervous system infection in childhood and as the possible etiology for obscure, severe neurological disturbances in the pediatric age groups.     

The 1952 outbreak of encephalitis in California; epidemiologic aspects

For the most part, epidemiologic phenomena observed in the outbreak of encephalitis in 1952 accorded with patterns that had been apparent in previous years. Ninety-seven per cent of the 414 laboratory-confirmed cases of western equine and St. Louis encephalitis in humans occurred in the 20 Central Valley counties. The cases of western equine encephalomyelitis in horses were generally scattered over the state. In the Central Valley most of the cases in horses were in animals less than two years of age; elsewhere the incidence was higher in older horses.There were no laboratory-confirmed cases of western equine or St. Louis encephalitis in humans earlier than June or later than October. In 1952 there were far more cases of western equine than of St. Louis encephalitis-a departure from the pattern in the previous seven years when there were about as many of one as of the other. No known satisfactory index is available for the prediction of the extent or type of outbreaks in humans. Approximately one-third of the cases of western equine encephalitis were in patients less than one year of age, whereas there were no cases of the St. Louis disease in patients that young.The incidence of western equine encephalitis in persons under 5 years of age was about the same for girls as for boys. In higher age brackets, males with western equine encephalitis outnumbered females 2 to 1. The corresponding ratio for St. Louis encephalitis was only 1.2 to 1.     

Pulmonary Resection in Infancy and Childhood

In a study of the spinal fluid chloride levels at the time of admission to hospital in a series of 1,788 cases of suspected meningitis, it was noted that the chloride content was not depressed in poliomyelitis, viral meningitis and encephalitis. In pyogenic meningitides, the spinal fluid chlorides were moderately depressed. More pronounced depression was noted in tuberculous and fungal meningitides.     

Sero-Molecular Epidemiology of Japanese Encephalitis in Zhejiang,an Eastern Province of China

BackgroundSporadic Japanese encephalitis (JE) cases still have been reported in Zhejiang Province in recent years, and concerns about vaccine cross-protection and population-level immunity have been raised off and on within the public health sphere. Genotype I (GI) has replaced GIII as the dominant genotype in Asian countries during the past few decades, which caused considerable concerns about the potential change of epidemiology characteristics and the vaccine effectiveness. The aim of this study was to investigate the prevalence of JE neutralizing antibody and its waning antibody trend after live attenuated JE vaccine immunization. Additionally, this study analyzed the molecular characteristics of the E gene of Zhejiang Japanese encephalitis virus (JEV) strains, and established genetic relationships with other JEV strains.Conclusion/SignificancesJE neutralizing antibody positive rates increase in age ≥10 years old population, likely reflecting natural infection or natural boosting of immunity through exposure to wild virus. JE seropositivity rates were quite low in <35 years old age groups in Zhejiang Province. Waning of neutralizing antibody after live attenuated vaccine immunization was observed, but the clinical significance should be further investigated. Both the peripheral antibody response and genetic characterization indicate that current live attenuated JE vaccine conferred equal neutralizing potency against GI or GIII of wild strains. GI has replaced GIII as the dominant genotype in Zhejiang in the past few decades. Although the chance of exposure to wild JE virus has reduced, the virus still circulates in nature; therefore, it is necessary to implement immunization program for children continually and to conduct surveillance activity periodically.     

No evidence for prolonged excretion of polioviruses in persons with residual paralytic poliomyelitis in Ethiopia, Pakistan and Guatemala.

Persons who have developed acute flaccid paralysis following infection with wild-type polioviruses or vaccine-associated paralytic poliomyelitis usually excrete polioviruses for only a few weeks. However, some patients with paralytic poliomyelitis have had prolonged excretion of polioviruses for periods of up to 10 years after onset of disease. Most prolonged excretors have been identified in industrialized countries. We studied 348 patients 2-28 years old in Ethiopia, Pakistan and Guatemala with residual paralytic poliomyelitis to determine if they had IgA or IgG deficiency or persistent poliomyelitis excretion at least 1 year after onset of disease. None of the 348 affected individuals had IgG deficiency or persistent poliovirus excretion. One child had borderline low serum IgA concentration. Since we did not study children under 2 years of age, persons born with IgG deficiency disorders may have died in developing countries where replacement immunoglobulin therapy is not readily available. Nevertheless, persistent poliovirus excretion among persons 2 years of age and older with residual paralytic poliomyelitis is uncommon in developing countries.     

West Nile Virus Retinopathy and Associations with Long Term Neurological and Neurocognitive Sequelae

West Nile virus (WNV) has emerged as an important vector-borne pathogen in North America, with more than 3 million estimated to have been infected. Retinopathy from WNV infection has been previously reported in acute cases, though those prior reports did not evaluate the risk of retinopathy based on clinical severity of neurologic disease. The purpose of this cross-sectional study was to perform comprehensive ophthalmological and neurological examinations on 111 patients with a history of West Nile virus infection and describe the ocular manifestations. Out of 111 patients, 27 (24%) had evidence for West Nile virus associated retinopathy (WNVR); this observation was higher (49%) in those patients who initially presented with encephalitis. Individuals with WNVR had more frequent involvement of the macula and peripheral involvement compared to those patients without WNVR (p<0.05). WNVR was also associated with a greater likelihood of abnormal reflexes on neurological exam, poorer learning, greater dependence in activities of daily living, and lower quality of life (p<0.05). WNVR was seen more frequently in elderly patients (age > 60 years), and was associated with higher rates of diabetes mellitus and a history of encephalitis (p<0.05). A multivariable logistic regression revealed that only a history of encephalitis was independently associated with WNVR [Adjusted Odds Ratio = 4.9 (1.8–13.2); p = 0.001]. Our study found that WNVR occurs in one fourth of patients with a history of WNV infection and is more frequently observed in those with apparent severe neurological sequelae (e.g., encephalitis). The clinical relevance of WNVR was supported by its associations with dependence in activities of daily living and lower quality of life. This unique evaluation of WNV patients included fundoscopic examinations and their associations with neurologic impairment. Our findings can be used during ophthalmological consultation for the evaluation, treatment and rehabilitation phases of care for WNV patients.     

Immunity of children to diphtheria,tetanus, and poliomyelitis.

A survey of titres of diphtheria and tetanus antitoxins and of antibodies to polioviruses in the sera of 291 schoolchildren aged 15, 11, and 7 years showed that high immunisation rates can evoke protective concentrations of tetanus antitoxin in 98% of children and protective levels of the antibodies to diphtheria and all three types of poliomyelitis in 85% of children. Reinforcing immunisation at school entry appeared to be necessary to maintain adequate titres of diphtheria antitoxin in children up to 15 years of age, not essential to maintain adequate titres of tetanus antitoxin, and to have little effect on the titres of antibodies to poliomyelitis.     

RELATION OF A STREPTOCOCCUS TO EPIDEMIC POLIOMYELITIS—Studies in Etiology,Diagnosis and Specific Treatment

The production in 1915 of herpes zoster or “posterior” poliomyelitis in animals with a streptococcus led to further research on the etiologic importance of streptococci in “anterior” poliomyelitis.A specific streptococcus was demonstrated consistently in persons with poliomyelitis and in well persons having contact with them or merely inhabiting an area in which poliomyelitis was epidemic. That the organism was not present in areas remote from contact with the disease was likewise demonstrated.The streptococcus has been isolated from filtrates of poliomyelitis virus and from the tissues and exudates which harbor the virus. It appears in the spinal fluid in the preparalytic stage of poliomyelitis and disappears from the spinal fluid during the severe stage of the disease.Antibody and antigen prepared from the streptococcus were used to determine the presence of antigen and antibody indicative of streptococcal infection in many patients with poliomyelitis and in well persons. The intensity of reaction indicating specific streptococcal antigen was directly proportional to the degree of paralysis in patients; the reaction was greater in persons whose age, sex and previous isolation from the disease would normally indicate greater susceptibility. The test for antibody gave opposite results.Specific agglutinins for the streptococcus and neutralizing antibody for the virus were present consistently in the serum of persons and monkeys during recovery from poliomyelitis.Virus produced in vitro from the associated streptococcus caused all the clinical and pathologic features of poliomyelitis in monkeys inoculated with it, and the animals that recovered from the disease thus induced were proved to be immune thereafter to the natural virus.Antistreptococcic serum prepared in horses was used to treat poliomyelitis. In a group of monkeys inoculated with the virus of the disease, 6 per cent of those receiving the serum before inoculation died of the disease; of the control group, 82 per cent. In a series of poliomyelitis patients treated with the serum the mortality rate was 8 per cent; in a control series, 21 per cent. In a series treated in all stages of the disease by the author, 10 per cent died; of those who did not receive the serum, 25 per cent.An antibody has been prepared from the streptococcus which appears to prevent paralysis and otherwise mitigate poliomyelitis and to provide immunization from the disease.The conclusion is reached that the virus of poliomyelitis is a form of the specific streptococcus, which is the agent in primary infections and in the development of the immunizing antibody.     

RELATION OF A STREPTOCOCCUS TO EPIDEMIC POLIOMYELITIS-Studies in Etiology,Diagnosis and Specific Treatment

The production in 1915 of herpes zoster or "posterior" poliomyelitis in animals with a streptococcus led to further research on the etiologic importance of streptococci in "anterior" poliomyelitis.A specific streptococcus was demonstrated consistently in persons with poliomyelitis and in well persons having contact with them or merely inhabiting an area in which poliomyelitis was epidemic. That the organism was not present in areas remote from contact with the disease was likewise demonstrated.The streptococcus has been isolated from filtrates of poliomyelitis virus and from the tissues and exudates which harbor the virus. It appears in the spinal fluid in the preparalytic stage of poliomyelitis and disappears from the spinal fluid during the severe stage of the disease. Antibody and antigen prepared from the streptococcus were used to determine the presence of antigen and antibody indicative of streptococcal infection in many patients with poliomyelitis and in well persons. The intensity of reaction indicating specific streptococcal antigen was directly proportional to the degree of paralysis in patients; the reaction was greater in persons whose age, sex and previous isolation from the disease would normally indicate greater susceptibility. The test for antibody gave opposite results. Specific agglutinins for the streptococcus and neutralizing antibody for the virus were present consistently in the serum of persons and monkeys during recovery from poliomyelitis. Virus produced in vitro from the associated streptococcus caused all the clinical and pathologic features of poliomyelitis in monkeys inoculated with it, and the animals that recovered from the disease thus induced were proved to be immune thereafter to the natural virus. Antistreptococcic serum prepared in horses was used to treat poliomyelitis. In a group of monkeys inoculated with the virus of the disease, 6 per cent of those receiving the serum before inoculation died of the disease; of the control group, 82 per cent. In a series of poliomyelitis patients treated with the serum the mortality rate was 8 per cent; in a control series, 21 per cent. In a series treated in all stages of the disease by the author, 10 per cent died; of those who did not receive the serum, 25 per cent. An antibody has been prepared from the streptococcus which appears to prevent paralysis and otherwise mitigate poliomyelitis and to provide immunization from the disease.The conclusion is reached that the virus of poliomyelitis is a form of the specific streptococcus, which is the agent in primary infections and in the development of the immunizing antibody.     

Simultaneous Immunization with B.C.G., Diphtheria-tetanus,and Oral Poliomyelitis Vaccines in Children Aged 13-14

The simultaneous administration of B.C.G. vaccine, diphtheria-tetanus toxoid aluminium hydroxide adsorbed vaccine, and oral poliovaccine was studied in 628 children aged 13-14 years between 1966 and 1969 in Newham, London. The efficacy of these vaccines was unaffected by administering them at the same time; routine simultaneous administration is considered justified when organizational difficulties prevent the attainment of high immunization rates with the vaccines given separately. No adverse reactions to B.C.G. or oral poliomyelitis vaccines took place, but 8% of children had moderately severe local reactions after diphtheria-tetanus aluminium hydroxide adsorbed vaccine, which were attributed to diphtheria toxoid.Serological studies showed the need for immunization against diphtheria, tetanus, and poliomyelitis at 13-14 years of age. Because of the adverse reactions to diphtheria toxoid, however, simultaneous administration of tetanus toxoid aluminium hydroxide adsorbed, oral poliomyelitis, and B.C.G. vaccines only is recommended at present.An “adult type” diphtheria-tetanus toxoid might overcome the problem of reactions, though in two to three years'' time most children aged 13-14 years will have received diphtheria-tetanus-pertussis vaccine in infancy and reinforcement might then be accomplished by a small intradermal dose of the currently available fluid diphtheria-tetanus vaccine.Continued serological studies of diphtheria and tetanus antitoxins and polio antibody are necessary to determine the future need for reinforcement of immunity; such studies should become an essential part of the surveillance of the community immunization programme.     

Clinical Surveillance After Feeding Oral Attenuated Live Polio Vaccine

During widespread administration of oral poliomyelitis vaccine in the United States and Canada, a number of neurological conditions occurring within 30 days of vaccine administration were reported. After careful investigation, 11 cases of paralytic poliomyelitis in the United States and four cases in Canada have been accepted as being most probably vaccine-associated.The case of a 35-year-old man who developed paralytic poliomyelitis 17 days after taking oral vaccine is reported. Type III Poliovirus was isolated from his stools, and subsequent virological investigation of this virus strain suggested that it most likely was the attenuated strain. The McBride test gave an NK value of 90 and the rct/40 marker was positive. A rise in Type III antibodies was found in the patient''s serum, and increased neurovirulence was demonstrated by intracerebral inoculation of monkeys.Since many cases of neurological involvement have not been accepted as vaccine-associated because of the lack of adequate early investigations, active clinical surveillance after oral polio vaccine administration is urged, and appropriate studies should be carried out in suspect neurological complications.     

Is poliomyelitis a serious problem in developing countries?--lameness in Ghanaian schools.

A postal survey of lameness in schools throughout Ghana showed an estimated prevalence of lameness attributable to poliomyetitis of 5-8 per 1000 school-aged children and an estimated mean annual incidence of paralytic poliomyelitis of 23 per 100 000 population. Official reported incidence rates range from 0-1 to 2-1 per 100 000 population, indicating that at least 90% of cases are not reported. No evidence of epidemics was found to account for these high rates. These suggest that mean annual incidence rates in tropical endemic countries have always been as great, if not greater, than those experienced by temperate countries during epidemic periods in the twentieth century and that the total number of cases of paralytic poliomyelitis occurring in the world each year has been reduced by only 25% since the advent of polio vaccine. Immunisation against poliomyelitis must have a high priority in Ghana and other tropical countries where the disease is endemic.     

Poliomyelitis in Tajikistan. Protection of Russia from emergence and spread of wild poliomyelitis virus

Problem of emergence and spread of poliomyelitis in Russian Federation and neighboring states is examined. Measures taken in Russian Federation to prevent emergence of poliomyelitis cases caused by wild type virus are discussed, as well as treaties and agreements between Russia, Commonwealth of Independent States, Shanghai Cooperation Organization states regarding epidemiological control of poliomyelitis and acute flaccid paralysis. Measure planned by Federal Service for Surveillance for Protection of Consumers Rights and Human Welfare to prevent emergence of poliomyelitis and acute flaccid paralysis cases in Russian Federation and neighboring countries are presented.     

Tourette syndrome: clinical and psychological aspects of 250 cases.

Tourette syndrome is a common hereditary neuropsychiatric disorder consisting of multiple tics and vocal noises. We summarize here clinical aspects of 250 consecutive cases seen over a period of 3 years. The sex ratio was four males to one female, and the mean age of onset was 6.9 years. Only 10% were Jewish, indicating that it is not more prevalent in Ashkenazi Jews. Only 33% had compulsive swearing (coprolalia), indicating that this is not necessary for the diagnosis. The most frequent initial symptoms were rapid eye-blinking, facial grimacing, and throat-clearing. In this series, it was clear that Tourette syndrome is a psychiatric as well as a neurological disorder. Significant discipline problems and/or problems with anger and violence occurred in 61%, and 54% had attention-deficit disorder with hyperactivity. Some degree of exhibitionism was present in 15.9% of males and 6.1% of females. Obsessive-compulsive behavior was seen in 32%. Other than tics and vocal noises, the most common parental complaints were of short temper and everything being a confrontation. There were no significant clinical differences between familial and sporadic cases. Whenever a child presents with a learning disorder, attention-deficit disorder, or significant discipline or emotional problems, the parents should be questioned about the presence of tics or vocal noises in the patient and other family members.